Cervical cancer

Cervical cancer is a cancer arising from the cervix.

[1]
It is due to the abnormal growth of
cells that have the ability to invade or spread to other parts of the body.
[2]
Early on there are
typically no symptoms. Later symptoms may include: abnormal vaginal bleeding, pelvic pain
or pain during sexual intercourse.Worldwide, cervical cancer is both the fourth most common
cause of cancer and the fourth most common cause of death from cancer in women.
[5]
In
2012, it was estimated that there were 528,000 cases of cervical cancer, and 266,000 deaths.
History
400 BCE - Hippocrates: cervical cancer incurable
1925 - Hinselmann: invented colposcope
1928 - Papanicolaou: developed Papanicolaou technique
1941 - Papanicolaou and Trout: Pap smear screening
1946 - Ayer: Aylesbury spatula to scrape the cervix, collecting sample for Pap smear
1951 - First successful in-vitro cell line, HeLa, derived from biopsy of cervical cancer
of Henrietta Lacks
1976 - Zur Hausen and Gisam: found HPV DNA in cervical cancer and warts
1988 - Bethesda System for reporting Pap results developed
2006 - First HPV vaccine FDA approved
Cancer subtypes
Histologic subtypes of invasive cervical carcinoma include the following:
[36][37]
Though
squamous cell carcinoma is the cervical cancer with the most incidence, the incidence of
adenocarcinoma of the cervix has been increasing in recent decades.
[3]

squamous cell carcinoma (about 80-85%
[citation needed]
)
adenocarcinoma (about 15% of cervical cancers in the UK
[34]
)
adenosquamous carcinoma
small cell carcinoma
neuroendocrine tumour
glassy cell carcinoma
villoglandular adenocarcinoma
Non-carcinoma malignancies which can rarely occur in the cervix include
melanoma lymphoma

Staging
Main article: Cervical cancer staging
Cervical cancer is staged by the International Federation of Gynecology and Obstetrics
(FIGO) staging system, which is based on clinical examination, rather than surgical findings.
It allows only the following diagnostic tests to be used in determining the stage: palpation,
inspection, colposcopy, endocervical curettage, hysteroscopy, cystoscopy, proctoscopy,
intravenous urography, and X-ray examination of the lungs and skeleton, and cervical
conization.
Stage 1A cervical cancer
Stage 1B cervical cancer
Stage 2A cervical cancer
Stage 2B cervical cancer
Stage 3B cervical cancer
Stage 4A cervical cancer
Stage 4B cervical cancer
Vaccination
There are two HPV vaccines (Gardasil and Cervarix) which reduce the risk of cancerous or
precancerous changes of the cervix and perineum by about 93% and 62%, respectively.
[49]

HPV vaccines are typically given to women age 9 to 26 as the vaccine is only effective if
given before infection occurs. The vaccines have been shown to be effective for at least 4
[50]

to 6
[51]
years, and it is believed they will be effective for longer;
[52]
however, the duration of
effectiveness and whether a booster will be needed is unknown. The high cost of this vaccine
has been a cause for concern. Several countries have considered (or are considering)
programs to fund HPV vaccination.
Nutrition
Vitamin A is associated with a lower risk
[58]
as is vitamin B12, vitamin C, vitamin E, and
beta-carotene.
[59]

Vaccination and public health
The National Cancer Institute states "Widespread vaccination has the potential to reduce
cervical cancer deaths around the world by as much as two-thirds, if all women were to take
the vaccine and if protection turns out to be long-term. In addition, the vaccines can reduce
the need for medical care, biopsies, and invasive procedures associated with the follow-up
from abnormal Pap tests, thus helping to reduce health care costs and anxieties related to
abnormal Pap tests and follow-up procedures."
[22]

Research directions
There are high-risk HPV types, that are not affected by the vaccines.
[37]
Ongoing research is
focused on the development of HPV vaccines that will offer protection against a broader
range of HPV types.
[80]
One such method is a vaccine based on the minor capsid protein L2,
which is highly conserved across HPV genotypes.
[81]
Efforts for this have included boosting
the immunogenicity of L2 by linking together short amino acid sequences of L2 from
different oncogenic HPV types.
[82]

There is also substantial research interest in the development of therapeutic vaccines, which
seek to elicit immune responses against established HPV infections and HPV-induced
cancers.
[83]

Therapeutic vaccines
In addition to preventive vaccines, such as Gardasil and Cervarix, laboratory research and
several human clinical trials are focused on the development of therapeutic HPV vaccines.
HPV-associated diseases have become an ideal test of antigen-specific immunotherapy due to
the expression of viral oncoproteins that provide tumour-specific non-self antigenic
targets.
[citation needed]
The relative accessibility of the lower genital tract makes it easier to study
the effect of therapeutic vaccines on the systemic circulation and the target tissue.
[citation needed]

In general these vaccines focus on the main HPV oncogenes, E6 and E7. Since expression of
E6 and E7 is required for promoting the growth of cervical cancer cells (and cells within
warts), it is hoped that immune responses against the two oncogenes might eradicate
established tum There is a working therapeutic HPV vaccine that has been clinically tried in
Mexico. Developed by Ricardo Rosales. It has gone through 3 clinical trials and has been
approved for use by the Mexican government. It is a MVA based vaccine with an e2 bovine
protein added in. It has been shown to completely eliminate HPV to the point that patients
test negative for the presence of HPV in blood tests. The vaccine is officially called the MEL-
1 Vaccine but also known as the MVA-E2 vaccine. The vaccine has proven to be safe as far
as is known there have been no side effects or other documented issues. The Vaccine is
administered locally to the infected areas and also given in the arm if the infection is
mild.ors.
[84]

Vaccine implementation
Main article: Vaccination policy
In developed countries, the widespread use of cervical "Pap smear" screening programs has
reduced the incidence of invasive cervical cancer by 50% or more. Current preventive
vaccines reduce, but do not eliminate the chance of getting cervical cancer. Therefore, experts
recommend that women combine the benefits of both programs by seeking regular Pap smear
screening, even after vaccination.
[91]
The European Centre for Disease Prevention and
Control (ECDC) has recommended all European teenage girls to be vaccinated however
Bulgaria, Cyprus, Czech Republic, Estonia, Finland, Lithuania, Poland, Slovakia and Turkey
currently do not have a vaccination programme in place.
What the human papilloma virus (HPV) is
There are over 100 different types of human papilloma virus (HPV). It is sometimes called
the wart virus or genital wart virus because some types of HPV cause genital warts. A
number of HPV types are passed on from one person to another through sexual contact. Many
women will be infected with the HPV virus at some point during their lifetime. Often the
virus causes no harm and goes away without treatment.
HPV and cancer
Some types of HPV can increase the risk of developing cervical cancer. Cervical cancer is
cancer of the neck of the womb. Around 3100 women are diagnosed with this type of cancer
every year in the UK. Most women infected with HPV dont go on to develop cervical
cancer. But for some, infection with HPV can go on to cause
Genital warts
Changes in the cervix, which may develop into cervical cancer
Changes in the vaginal tissues, which may develop into vaginal cancer
Of the different types of HPV, types 16 and 18 cause about 7 out of 10 (70%) cancers
of the cervix. Most of the remaining 30% of cervical cancers are associated with other
high risk HPV types. HPV types 6 and 11 cause genital warts but are rarely linked to
cancer. You can find out more about the risks and causes of cervical cancer in our
cervical cancer section. HPV is also a risk factor for other types of cancer including
vulval cancer, anal cancer, cancer of the penis and mouth and oropharyngeal cancers

Research into vaccines to prevent HPV
Several research trials have tested vaccines as a way of preventing infection with HPV. There
are 2 cervical cancer vaccines, Gardasil and Cervarix. A trial testing Gardasil called
FUTURE II reported its results in October 2005. This phase 3 trial involved over 12,000
women aged between 16 and 26. These women did not have HPV before the start of the trial.
The women were divided into 2 groups. Half the women were given Gardasil and the other
half had a dummy vaccine (placebo). Both groups of women had 3 injections of either the
vaccine or placebo over 6 months.
Over the following 2 years the women had regular checks to see if they had got HPV, or had
any pre cancerous changes to the cells of the cervix, which could develop into a cancer. The
group who had the vaccine showed no pre cancerous changes. Of the 5,258 women who had
the placebo, 21 had pre cancerous changes, which is 0.4%. The researchers found that
Gardasil protected against HPV types 6 and 11 (which cause about 90% of genital warts), as
well as 16 and 18. Gardasil was licensed in the UK in September 2006 for girls and women
aged between 9 and 26.
Two phase 3 trials have tested the vaccine Cervarix. The first was for women under 26. It
involved over 18,000 women from all over the world, including the UK. This study was
called PATRICIA (PApilloma TRIal to prevent Cervical cancer In young Adults). The
second was for women of 26 and over. The trials found that Cervarix was useful in
preventing HPV infection. Cervarix was licensed in the UK in 2007 for the prevention of pre
cancerous changes in the cervix in girls and women between the age of 10 and 25.
Research has shown that Gardasil can help to prevent the development of anal warts and anal
cancers. There is research looking at whether the vaccine can prevent other types of cancer.
At the moment we dont know whether the vaccine can prevent HPV infection in the mouth.
There is research going on to look at the link between HPV and other types of cancer and
how to prevent it.
Side effects of the HPV vaccine
The side effects are usually mild and may include
Headache
Dizziness
Aching muscles
Redness and soreness around the site of the injection
A slightly raised temperature
Feeling and being sick
Stomach pain
Diarrhoea
Itching and a skin rash
Targeted therapy
As researchers have learned more about the gene changes in cells that cause cancer, they have been able to
develop newer drugs that specifically target these changes. These targeted drugs work differently from standard
chemotherapy drugs. They often have different (and less severe) side effects. These drugs may be used alone or
with more traditional chemotherapy. Bevacizumab (Avastin), which can be used with chemo to treat advanced
cervical cancer, is an example of a targeted therapy drug.
Pazopanib is a type of targeted therapy drug that blocks the effect of certain growth factors on cancer
cells. In studies of patients with advanced cervical cancer, it helped them live longer

therapy for cervical cancer
Radiation : Radiation therapy uses high energy x-rays to kill cancer cells. These x-rays can be given
externally in a procedure that is much like having a diagnostic x-ray. This is called external beam radiation
therapy. This treatment usually takes 6 to 7 weeks to complete. For cervical cancer, this type of radiation
therapy is often given along with low doses of chemotherapy with a drug called cisplatin.
Another type of radiation therapy is called brachytherapy, or internal radiation therapy. To treat cervical cancer
in women who have had a hysterectomy, the radioactive material is placed in a cylinder in the vagina. To treat a
woman who still has a uterus, the radioactive material is placed in a small metal tube called a tandem that goes
in the uterus, along with small round metal holders called ovoids placed near the cervix. This is sometimes
called tandem and ovoid treatment.
To treat some cancers, radioactive material is placed in thin needles that are inserted directly in the tumor. This
form of brachytherapy is not often used in the treatment of cervical cancer.
There are 2 main types of brachytherapy treatment: low-dose rate and high-dose rate. Low-dose rate
brachytherapy is completed in just a few days. During that time, the patient remains in bed the hospital with
instruments holding the radioactive material in place. High-dose rate brachytherapy is done as an outpatient over
several treatments. For each high-dose treatment, the radioactive material is inserted for a few minutes and then
removed. The advantage of high-dose rate treatment is that you do not have to stay still for long periods of time.
Common side effects of external beam radiation therapy include:
Fatigue (tiredness)
Upset stomach
Diarrhea or loose stools
Nausea and vomiting
Radiation to the pelvis can also irritate the bladder (radiation cystitis), causing discomfort and an urge to urinate
often. Pelvic radiation can also lead to premature menopause.
Skin changes are also common. As the radiation passes through the skin to the cancer, it may damage the skin
cells. This can cause irritation ranging from mild, temporary redness to peeling. The skin may release fluid,
which can lead to infection, so the area exposed to radiation must be carefully cleaned and protected. Radiation
can affect the vulva and vagina, making them sensitive and sore, and sometimes causing a discharge. This can
be seen with both brachytherapy and external beam radiation.
Radiation can also affect the ovaries, leading to menstrual changes and even early menopause
Radiation can also lead to low blood counts, which can cause:
Anemia (low red blood cells), which can cause you to feel tired
Leukopenia (low white blood cells), which increases the risks of serious infection
The blood counts return to normal in the weeks after radiation is stopped..
These side effects tend to be worse when chemotherapy is given with radiation.
Pelvic radiation therapy may cause scar tissue to form in the vagina. The scar tissue can make the vagina more
narrow (called vaginal stenosis) or even shorter, which makes vaginal intercourse painful. A woman can help
prevent this problem by stretching the walls of her vagina several times a week. Although this can be done by
engaging in sexual intercourse 3 to 4 times per week, most women find that hard to do during treatment. The
other way to stretch out the walls of the vagina is by using a vaginal dilator (a plastic or rubber tube used to
stretch out the vagina). A woman getting pelvic radiation does not have to start using the dilator during the
weeks that radiation is being given, but she should start by 2 to 4 weeks after treatment ends. Because it can take
a long time to see the effects of radiation, some experts recommend that the dilator be used indefinitely.
Vaginal dryness and painful intercourse can be long-term side effects from radiation. Vaginal (local) estrogens
may help with vaginal dryness and changes to the vaginal lining, especially if radiation to the pelvis damaged
the ovaries, causing early menopause. More information about managing the sexual side effects of cervical
cancer treatment can be found in our document Sexuality for the Woman with Cancer.
Radiation to the pelvis can also weaken the bones, leading to fractures. Hip fractures are the most common, and
might occur 2 to 4 years after radiation. Bone density studies are recommended.
Treating lymph nodes with radiation can lead to fluid drainage problems in the leg. This can cause severe
swelling in the leg, a condition called lymphedema.
If you are having side effects from radiation treatment, discuss them with your cancer care team.
It is important to know that smoking increases the side effects from radiation. If you smoke, you should stop.
A list of some documents about radiation treatments and its side effects can be found in the section called
Additional resources for cervical cancer.
Surgery :
Cryosurgery
A metal probe cooled with liquid nitrogen is placed directly on the cervix. This kills the abnormal cells by
freezing them. This can be done in a doctors office or clinic. After cryosurgery, you may have a lot of watery
brown discharge for a few weeks.
Cryosurgery is used to treat pre-cancers of the cervix (stage 0), but not invasive cancer.
Laser surgery
A focused laser beam, directed through the vagina, is used to vaporize (burn off) abnormal cells or to remove a
small piece of tissue for study. This can be done in a doctors office or clinic and is done under local anesthesia
(numbing medicine). Laser surgery is used to treat pre-cancers of the cervix (stage 0). It is not used to treat
invasive cancer.
Conization
A cone-shaped piece of tissue is removed from the cervix. This is done using a surgical or laser knife (cold knife
cone biopsy) or using a thin wire heated by electricity (the loop electrosurgical, LEEP or LEETZ procedure).
(See the section, "How are cervical cancers and pre-cancers diagnosed?" for more information.) A cone biopsy
may be used to diagnose the cancer before additional treatment with surgery or radiation. It can also be used as
the only treatment in women with early (stage IA1) cancer who want to preserve their ability to have children
(fertility). After the biopsy, the tissue removed (the cone) is examined under the microscope. If the margins
(outer edges) of the cone contain cancer (or pre-cancer) cells, further treatment will be needed to make sure that
all of the cancer is removed.
Hysterectomy
This is surgery to remove the uterus (both the body of the uterus and the cervix) but not the structures next to the
uterus (parametria and uterosacral ligaments). The vagina and pelvic lymph nodes are not removed. The ovaries
and fallopian tubes are usually left in place unless there is some other reason to remove them.
When the uterus is removed through a surgical incision in the front of the abdomen, it is called an abdominal
hysterectomy. When the uterus is removed through the vagina, it is called a vaginal hysterectomy. When the
uterus is removed using laparoscopy, it is called a laparoscopic hysterectomy. In some cases, laparoscopy is
performed with special tools to help the surgeon see better and with instruments that are controlled by the
surgeon. This is called robotic-assisted surgery.
General or epidural (regional) anesthesia is used for all of these operations. The recovery time and hospital stay
tends to be shorter for a laparoscopic or vaginal hysterectomy than for an abdominal hysterectomy. For a
laparoscopic or vaginal hysterectomy, the hospital stay is usually 1 to 2 days followed by a 2- to 3-week
recovery period. A hospital stay of 3 to 5 days is common for an abdominal hysterectomy, and complete
recovery takes about 4 to 6 weeks. Any type of hysterectomy results in infertility (inability to have children).
Complications are unusual but could include excessive bleeding, wound infection, or damage to the urinary or
intestinal systems.
Hysterectomy is used to treat stage IA1 cervical cancers. It is also used for some stage 0 cancers (carcinoma in
situ), if cancer cells were found at the edges of the cone biopsy (this is called positive margins). A hysterectomy
is also used to treat some non-cancerous conditions. The most common of these is leiomyomas, a type of benign
tumor commonly known as fibroids.
Sexual impact of hysterectomy: Hysterectomy does not change a woman's ability to feel sexual pleasure. A
woman does not need a uterus or cervix to reach orgasm. The area around the clitoris and the lining of the
vagina remain as sensitive as before.
Radical hysterectomy
For this operation, the surgeon removes the uterus along with the tissues next to the uterus (the parametria and
the uterosacral ligaments) and the upper part (about 1 inch) of the vagina next to the cervix. The ovaries and
fallopian tubes are not removed unless there is some other medical reason to do so. This surgery is usually
performed through an abdominal incision. Often, some pelvic lymph nodes are removed as well (this procedure,
known as lymph node dissection, is discussed later in this section).
Another surgical approach is called laparoscopic-assisted radical vaginal hysterectomy. This operation
combines a radical vaginal hysterectomy with a laparoscopic pelvic node dissection. Laparoscopy allows the
inside of the abdomen and pelvis to be seen through a tube inserted into very small surgical incisions. Small
instruments can be controlled through the tube, so the surgeon can remove lymph nodes through the tubes
without making a large cut in the abdomen. The laparoscope can also make it easier for the doctor to remove the
uterus, ovaries, and fallopian tubes through the vaginal incision. Laparoscopy can also be used to perform a
radical hysterectomy through the abdomen. Lymph nodes are removed as well. This is called laparoscopically
assisted radical hysterectomy with lymphadenectomy.
Robot-assisted laparoscopic surgery is also sometimes used to perform radical hysterectomies. The advantages
are lower blood loss and a shorter stay in the hospital after surgery. However, this way of treating cervical
cancer is still relatively new, and its ultimate role in treatment is still being studied.
More tissue is removed in a radical hysterectomy than in a simple one, so the hospital stay can be longer, about
5 to 7 days. Because the uterus is removed, this surgery results in infertility. Because some of the nerves to the
bladder are removed, some women have problems emptying their bladder after this operation. Complications are
unusual but could include excessive bleeding, wound infection, or damage to the urinary and intestinal systems.
A radical hysterectomy and pelvic lymph node dissection are the usual treatment for stages IA2, IB, and less
commonly IIA cervical cancer, especially in young women.
Sexual impact of radical hysterectomy: Radical hysterectomy does not change a woman's ability to feel
sexual pleasure. Although the vagina is shortened, the area around the clitoris and the lining of the vagina is as
sensitive as before. A woman does not need a uterus or cervix to reach orgasm. When cancer has caused pain or
bleeding with intercourse, the hysterectomy may actually improve a woman's sex life by stopping these
symptoms.
Trachelectomy
Most women with stage IA2 and stage IB are treated with hysterectomy. Another procedure, known as a radical
trachelectomy, allows some of these young women to be treated without losing their ability to have children.
This procedure removes the cervix and the upper part of the vagina but not the body of the uterus. The surgeon
places a "purse-string" stitch to act as an artificial opening of the cervix inside the uterine cavity. The nearby
lymph nodes are also removed using laparoscopy which may require another incision (cut). The operation is
done either through the vagina or the abdomen.
After trachelectomy, some women are able to carry a pregnancy to term and deliver a healthy baby by cesarean
section. In one study, the pregnancy rate after 5 years was more than 50%, but the women who had this surgery
had a higher risk of miscarriage than what is seen in normal healthy women. The risk of the cancer coming back
after this procedure is low.
Pelvic exenteration
This is a more extensive operation that may be used to treat recurrent cervical cancer. In this surgery, all of the
same organs and tissues are removed as in a radical hysterectomy with pelvic lymph node dissection (lymph
node dissection is discussed in the next section). In addition, the bladder, vagina, rectum, and part of the colon
may also be removed, depending on where the cancer has spread.
If the bladder is removed, a new way to store and eliminate urine will be needed. This usually means using a
short segment of intestine to function as a new bladder. The new bladder may be connected to the abdominal
wall so that urine is drained periodically when the patient places a catheter into a urostomy (a small opening).
Or urine may drain continuously into a small plastic bag attached to the front of the abdomen. For more
information about urostomies, see our document called Urostomy:A Guide.
If the rectum and part of the colon are removed, a new way to eliminate solid waste must be created. This is
done by attaching the remaining intestine to the abdominal wall so that fecal material can pass through a
colostomy (a small opening) into a small plastic bag worn on the front of the abdomen (more information about
colostomies can be found in our document, Colostomy:A Guide). It may be possible to remove the cancerous
part of the colon (next to the cervix) and reconnect the colon ends so that no bags or external appliances are
needed.
If the vagina is removed, a new vagina can be surgically created out of skin, intestinal tissue, or muscle and skin
(myocutaneous) grafts.
Sexual impact of pelvic exenteration: Recovery from total pelvic exenteration takes a long time. Most women
don't begin to feel like themselves again for 6 months after surgery. Some say it takes a year or two to adjust
completely.
Nevertheless, these women can lead happy and productive lives. With practice and determination, they can also
have sexual desire, pleasure, and orgasms.
Pelvic lymph node dissection
Cancer that starts in the cervix can spread to lymph nodes in the pelvis (lymph nodes are pea-sized collections
of immune system tissue). To check for lymph node spread, the surgeon might remove some of these lymph
nodes. This procedure is known as a lymph node dissection or lymph node sampling. It is done at the same
time as a hysterectomy (or trachelectomy). Removing lymph nodes can lead to fluid drainage problems in the
leg. This can cause severe swelling in the leg, a condition called lymphedema. More information about
lymphedema can be found in our document, Understanding Lymphedema For Cancers Other Than Breast
Cancer
Chemotherapy:
Systemic chemotherapy (chemo) uses anti-cancer drugs that are injected into a vein or given by mouth. These
drugs enter the bloodstream and can reach all areas of the body, making this treatment useful for killing cancer
cells in most parts of the body. Chemo is often given in cycles, with each period of treatment followed by a
recovery period.
When is chemotherapy used?
There are a few situations in which chemo may be recommended.
As a part of the main treatment: For some stages of cervical cancer, chemotherapy is given to help the
radiation work better. When chemotherapy and radiation therapy are given together, it is called concurrent
chemoradiation. One option is to give a dose of the drug cisplatin every week during radiation. This drug is
given into a vein (IV) about 4 hours before the radiation appointment. Another choice is to give cisplatin along
with 5-fluorouracil (5-FU) every 4 weeks during radiation. Other drug combinations are also used.
Sometimes chemo is also given (without radiation) before and/or after chemoradiation.
To treat cervical cancer that has come back after treatment or has spread: Chemo may also be used to treat
cancers that have spread to other organs and tissues. It can also be helpful when cancer comes back after
treatment with chemoradiation.
Drugs most often used to treat cervical cancer include:
Cisplatin
Carboplatin
Paclitaxel (Taxol

),
Topotecan
Gemcitabine (Gemzar

)
Often combinations of these are used.
Some other drugs can be used as well, such as docetaxel (Taxotere

), ifosfamide (Ifex

), 5-fluorouracil (5-FU),
irinotecan (Camptosar

), and mitomycin,
Side effects
Chemotherapy drugs kill cancer cells but also damage some normal cells, which can lead to certain side effects.
Side effects depend on the type of drugs, the amount taken, and the length of time you are treated. Common side
effects of chemotherapy can include:
Nausea and vomiting
Loss of appetite
Loss of hair
Mouth sores
Fatigue (tiredness)
Because chemotherapy can damage the blood-producing cells of the bone marrow, the blood cell counts might
become low. This can result in:
An increased chance of infection (from a shortage of white blood cells)
Bleeding or bruising after minor cuts or injuries (because of a shortage of blood platelets)
Shortness of breath (due to low red blood cell counts)
When chemo is given with radiation, the side effects are often more severe. The nausea and fatigue are often
worse. Diarrhea can also be a problem if chemo is given at the same time as radiation. Problems with low blood
counts can also be worse. Your healthcare team will watch for side effects and can give you medicines to
prevent them or help you feel better.
Most side effects are short-term and go away after treatment is finished. It's important to tell your healthcare
team if you have any side effects, as there are often ways to lessen them. For example, drugs can be given to
help prevent or reduce nausea and vomiting.
Other side effects are also possible. Some of these are more common with certain chemo drugs. Your cancer
care team will tell you about the possible side effects of the specific drugs you are getting.
Menstrual changes: For younger women who have not had their uterus removed as a part of treatment, changes
in menstrual periods are a common side effect of chemo. Premature menopause (not having any more menstrual
periods) and infertility (not being able to become pregnant) may occur and may be permanent. Some chemo
drugs are more likely to do this than others. The older a woman is when she receives chemo, the more likely it is
that she will become infertile or go through menopause as a result. When this happens, there is an increased risk
of bone loss and osteoporosis. There are medicines that can treat or help prevent problems with bone loss.
Even if your periods have stopped on chemo, you might still be able to get pregnant. Getting pregnant while
receiving chemo could lead to birth defects and interfere with treatment. This is why its important that women
who are pre-menopausal before treatment and are sexually active discuss using birth control with their doctor.
Patients who have finished treatment (like chemo) can safely go on to have children, but it's not safe to get
pregnant while on treatment.
Neuropathy: Some drugs used to treat cervical cancer, including paclitaxel and cisplatin, damage nerves
outside of the brain and spinal cord. This (called peripheral neuropathy) can sometimes lead to symptoms
(mainly in the hands and feet) like numbness, pain, burning or tingling sensations, sensitivity to cold or heat, or
weakness. In most cases this gets better or even goes away once treatment is stopped, but it might last a long
time in some women.
Increased risk of leukemia: Very rarely, certain chemo drugs can permanently damage the bone marrow,
leading to a disease called myelodysplastic syndrome or even acute myeloid leukemia, a life-threatening cancer
of white blood cells. If this is going to happen, it is usually within 10 years after treatment. In most women, the
benefits of chemo in treating the cancer are likely to far exceed the risk of this serious but rare complication.
See the section called Additional resources for cervical cancer for a list of some documents about chemo and
dealing with common side effects.
Targeted therapy :
As researchers have learned more about the changes in cancer cells, they have been able to develop newer drugs
that specifically target these changes. These targeted drugs work differently from standard chemotherapy
(chemo) drugs and often have different side effects.
For tumors to grow, they must form new blood vessels to keep them nourished. This process is called
angiogenesis. Some targeted drugs block this new blood vessel growth and are called angiogenesis inhibitors.
Bevacizumab (Avastin

) is an angiogenesis inhibitor that can be used to treat advanced cervical cancer. It is a

monoclonal antibody (a man-made version of a specific immune system protein) that targets vascular
endothelial growth factor (VEGF), a protein that helps new blood vessels to form. It isnt yet approved by the
US Food and Drug Administration to treat cervical cancer, but it is approved to treat other cancers.
This drug is often used with chemo for a time. Then if the cancer responds, the chemo may be stopped and the
bevacizumab given by itself until the cancer starts growing again.
The possible side effects of this drug are different from (and may add to) those of chemotherapy drugs. Some of
these effects can be serious and include problems with bleeding, blood clots, and wound healing.
This drug is also being studied as a part of the treatment for earlier stage disease.
Our document Targeted Therapy has more information about the different kinds of drugs considered targeted
therapy.
Clinical trials for cervical cancer
You may have had to make a lot of important decisions since youve been told you have cancer. One of the most
important decisions you will make is choosing which treatment is best for you. You may have heard about
clinical trials being done for your type of cancer. Or maybe someone on your health care team has mentioned a
clinical trial to you.
Clinical trials are carefully controlled research studies that are done with patients who volunteer for them. They
are done to get a closer look at promising new treatments or procedures.
If you would like to take part in a clinical trial, you should start by asking your doctor if your clinic or hospital
conducts clinical trials. You can also call our clinical trials matching service for a list of clinical trials that meet
your medical needs. You can reach this service at 1-800-303-5691 or on our Web site at
http://clinicaltrials.cancer.org. You can also get a list of current clinical trials by calling the National Cancer
Institute's Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237) or by visiting the NCI
clinical trials Web site at www.cancer.gov.
There are requirements you must meet to take part in any clinical trial. If you do qualify for a clinical trial, it is
up to you whether or not to enter (enroll in) it.
Clinical trials are one way to get state-of-the art cancer treatment. In some cases they may be the only way to get
access to newer treatments. They are also the only way for doctors to learn better methods to treat cancer. Still,
they are not right for everyone.
You can get a lot more information on clinical trials in our document called Clinical Trials: What You Need to
Know. You can read it on our Web site or call our toll-free number (1-800-227-2345) and have it sent to you.
Complementary and alternative therapies for cervical cancer
When you have cancer you are likely to hear about ways to treat your cancer or relieve symptoms that your
doctor hasn't mentioned. Everyone from friends and family to Internet groups and Web sites might offer ideas
for what might help you. These methods can include vitamins, herbs, and special diets, or other methods such as
acupuncture or massage, to name a few.
What exactly are complementary and alternative therapies?
Not everyone uses these terms the same way, and they are used to refer to many different methods, so it can be
confusing. We use complementary to refer to treatments that are used along with your regular medical care.
Alternative treatments are used instead of a doctor's medical treatment.
Complementary methods: Most complementary treatment methods are not offered as cures for cancer. Mainly,
they are used to help you feel better. Some methods that are used along with regular treatment are meditation to
reduce stress, acupuncture to help relieve pain, or peppermint tea to relieve nausea. Some complementary
methods are known to help, while others have not been tested. Some have been proven not be helpful, and a few
have even been found harmful.
Alternative treatments: Alternative treatments may be offered as cancer cures. These treatments have not been
proven safe and effective in clinical trials. Some of these methods may pose danger, or have life-threatening side
effects. But the biggest danger in most cases is that you may lose the chance to be helped by standard medical
treatment. Delays or interruptions in your medical treatments may give the cancer more time to grow and make
it less likely that treatment will help.
Finding out more
It is easy to see why people with cancer think about alternative methods. You want to do all you can to fight the
cancer, and the idea of a treatment with few or no side effects sounds great. Sometimes medical treatments like
chemotherapy can be hard to take, or they may no longer be working. But the truth is that most of these
alternative methods have not been tested and proven to work in treating cancer.
As you consider your options, here are 3 important steps you can take:
Look for "red flags" that suggest fraud. Does the method promise to cure all or most cancers? Are you
told not to have regular medical treatments? Is the treatment a "secret" that requires you to visit certain
providers or travel to another country?
Talk to your doctor or nurse about any method you are thinking about using
Contact us at 1-800-227-2345 to learn more about complementary and alternative methods in general
and to find out about the specific methods you are looking at. You can also check them out on the
Complementary and Alternative Medicine page of our Web site.
The choice is yours
Decisions about how to treat or manage your cancer are always yours to make. If you want to use a non-standard
treatment, learn all you can about the method and talk to your doctor about it. With good information and the
support of your health care team, you may be able to safely use the methods that can help you while avoiding
those that could be harmful.
Treating pre-cancers and other abnormal Pap test results
If you have abnormal results on a colposcopy (this was discussed in the section, "How are cervical cancers and
pre-cancers diagnosed?"), you may need treatment.
Abnormal areas seen on colposcopy can often be removed with a loop electrosurgical procedure (LEEP or
LLETZ) or a cold knife cone biopsy (these were discussed in the section, "How are cervical cancers and pre-
cancers diagnosed?"). Other options include destroying the abnormal cells with cryosurgery or laser surgery
(These were discussed in the surgery section.
During cryosurgery, the doctor uses a metal probe cooled with liquid nitrogen to kill the abnormal cells by
freezing them.
In laser surgery, the doctor uses a focused beam of high-energy light to vaporize (burn off) the abnormal tissue.
This is done through the vagina, with local anesthesia.
Both cryosurgery and laser surgery can be done in a doctor's office or clinic. After cryosurgery, you may have a
lot of watery brown discharge for a few weeks.
These treatments are almost always effective in destroying pre-cancers and preventing them from developing
into true cancers. You will need follow-up exams to make sure that the abnormality does not come back. If it
does, the treatments can be repeated.
Treatment options for cervical cancer by stage
The stage of a cervical cancer is the most important factor in choosing treatment. However, other factors that
affect this decision include the exact location of the cancer within the cervix, the type of cancer (squamous cell
or adenocarcinoma), your age, your overall physical condition, and whether you want to have children.
Stage 0 (carcinoma in situ)
Although the AJCC staging system classifies carcinoma in situ (CIS) as the earliest form of cancer, doctors
often think of it as a pre-cancer. That is because the cancer cells in CIS are only in the surface layer of the cervix
they have not grown into deeper layers of cells.
Treatment options for squamous cell carcinoma in situ are the same as for other pre-cancers (dysplasia or
cervical intraepithelial neoplasia [CIN]). Options include cryosurgery, laser surgery, loop electrosurgical
excision procedure (LEEP/LEETZ), and cold knife conization.
For adenocarcinoma in situ, hysterectomy is usually recommended. For women who wish to have children,
treatment with a cone biopsy may be an option. The cone specimen must have no cancer cells at the edges, and
the patient must be closely watched. After the woman has finished having children, a hysterectomy is
recommended.
A simple hysterectomy is also an option for treatment of squamous cell carcinoma in situ, and might be done if
it returns after other treatments. All cases of CIS can be cured with appropriate treatment. However, pre-
cancerous changes can recur (come back) in the cervix or vagina, so it is very important for your doctor to watch
you closely. This includes follow-up with regular Pap tests and in some instances with colposcopy.
Stage IA is divided into stage IA1 and stage IA2
Stage IA1: For this stage you have 3 options
If you still want to be able to have children, first the cancer is removed with a cone biopsy, and then
you are watched closely to see if the cancer comes back.
If the cone biopsy doesn't remove all of the cancer (or if you are done having children), the uterus will
be removed (hysterectomy).
If the cancer has invaded the blood vessels or lymph vessels, you might need a radical hysterectomy
along with removal of the pelvic lymph nodes. For women who still want to be able to have children, a
radical trachelectomy can be done instead of the radical hysterectomy.
Stage IA2: There are 3 treatment options
Radical hysterectomy along with removal of lymph nodes in the pelvis
Brachytherapy with or without external beam radiation therapy to the pelvis
Radical trachelectomy with removal of pelvic lymph nodes can be done if you still want to be able to
have children
If the cancer is found in any pelvic lymph nodes during surgery, some of the lymph nodes that lie along the
aorta (the large artery in the abdomen) may be removed as well. Any tissue removed at surgery will be
examined in the laboratory to see if the cancer has spread further than expected. If the cancer has spread to the
tissues next to the uterus (called the parametria) or to any lymph nodes, radiation therapy is usually
recommended. Often chemotherapy will be given with the radiation therapy. If the pathology report says that the
tumor had positive margins, this means that some cancer might have been left behind. This is also treated with
pelvic radiation (given with cisplatin chemotherapy). The doctor may advise brachytherapy, as well.
Stage IB is divided into stage IB1 and stage IB2
Stage IB1: There are 3 options available:
The standard treatment is a radical hysterectomy with removal of lymph nodes in the pelvis. Some
lymph nodes from higher up in the abdomen (called para-aortic lymph nodes) are also removed to see
if the cancer has spread there. If cancer cells are found in the edges of the tissues removed (positive
margins) or if cancer cells are found in lymph nodes during this operation, radiation therapy may be
given, possibly with chemotherapy, after surgery.
The second treatment option is radiation with both brachytherapy and external beam radiation therapy.
Radical trachelectomy with removal of pelvic (and some para-aortic) lymph nodes is an option if the
patient still wants to be able to have children
Stage IB2: There are 3 options available
The standard treatment is the combination of chemotherapy with cisplatin and radiation therapy to the
pelvis plus brachytherapy.
Another choice is radical hysterectomy with removal of pelvic (and some para-aortic) lymph nodes. If
cancer cells are found in the lymph nodes removed, or in the margins, radiation therapy may be given,
possibly with chemotherapy, after surgery.
Some doctors advise radiation given with chemotherapy (first option) followed by a hysterectomy.
Stage II is divided into stage IIA and stage IIB
Stage IIA: Treatment for this stage depends on the size of the tumor.
One choice for treatment is brachytherapy and external radiation therapy. This is most often
recommended if the tumor is larger than 4 cm (about 1 inches). Chemotherapy with cisplatin will be
given along with the radiation.
Some experts recommend removing the uterus after the radiation therapy is done.
If the cancer is not larger than 4 cm, it may be treated with a radical hysterectomy and removal of
lymph nodes in the pelvis (and some in the para-aortic area). If the tissue removed at surgery shows
cancer cells in the margins or cancer in the lymph nodes, radiation treatments to the pelvis will be
given with chemotherapy. Brachytherapy may be given as well.
Stage IIB: Combined internal and external radiation therapy is the usual treatment. The radiation is given with
the chemotherapy drug cisplatin. Sometimes other chemo drugs may be given along with cisplatin.
Stage III and IVA
Combined internal and external radiation therapy given with cisplatin is the recommended treatment.
If cancer has spread to the lymph nodes (especially those in the upper part of the abdomen) it can be a sign that
the cancer has spread to other areas in the body. Some experts recommend checking the lymph nodes for cancer
before giving radiation. One way to do this is by surgery. Another way is to do a CT or MRI scan to see how big
the lymph nodes are. Lymph nodes that are bigger than usual are more likely to have cancer. Those lymph nodes
can be biopsied to see if they contain cancer. If lymph nodes in the upper part of the abdomen (the para-aortic
lymph nodes) are cancerous, doctors may want to do other tests to see if the cancer has spread to other parts of
the body.
Stage IVB
At this stage, the cancer has spread out of the pelvis to other areas of the body. Stage IVB cervical cancer is not
usually considered curable. Treatment options include radiation therapy to relieve the symptoms of cancer that
has spread to the areas near the cervix or to distant sites (such as the lungs or bone). Chemo is often
recommended. Most standard regimens use a platinum compound (such as cisplatin or carboplatin) along with
another drug such as paclitaxel (Taxol), gemcitabine (Gemzar), or topotecan. The targeted drug bevacizumab
(Avastin) may be given along with chemo. Clinical trials are testing other combinations of chemo drugs, as well
as some other experimental treatments.
Recurrent cervical cancer
Cancer that comes backs after treatment is called recurrent cancer. Cancer can come back locally (in the pelvic
organs near the cervix) or come back in distant areas (spread through the lymphatic system and/or the
bloodstream to organs such as the lungs or bone).
If the cancer has recurred in the pelvis only, extensive surgery (by pelvic exenteration) may be an option for
some patients. This operation may successfully treat 40% to 50% of patients. (See the discussion in the section
about surgery) Sometimes radiation or chemotherapy may be used for palliative treatment (treatment to relieve
symptoms but not expected to cure).
If your cancer has recurred in a distant area, chemo or radiation therapy may be used to treat and relieve specific
symptoms. If chemo is used, you should understand the goals and limitations of this therapy. Sometimes chemo
can improve your quality of life, and other times it can diminish it. You need to discuss this with your doctors.
Fifteen percent to 25% of patients may respond at least temporarily to chemo.
New treatments that may benefit patients with distant recurrence of cervical cancer are being evaluated in
clinical trials. You may want to think about participating in a clinical trial.
Cervical cancer in pregnancy
A small number of cervical cancers are found in pregnant women. If your cancer is a very early cancer, such as
stage IA, then most doctors believe that it is safe to continue the pregnancy to term. Several weeks after
delivery, a hysterectomy or a cone biopsy is recommended (the cone biopsy is suggested only for substage IA1).
If the cancer is stage IB or higher, then you and your doctor must decide whether to continue the pregnancy. If
not, treatment would be radical hysterectomy and/or radiation. If you decide to continue the pregnancy, the baby
should be delivered by cesarean section as soon as it is able to survive outside the womb. More advanced
cancers, should be treated immediately.
Why you need treatment
If you have an abnormal cervical screening test result, you have changes in the cells covering
the neck of your womb (cervix). If these abnormal cells are left untreated, there is a risk that
some of them could go on to develop into cervical cancer in the future. Your screening result
may say you have
Borderline or mild cell changes (low grade dyskaryosis)
Moderate or severe cell changes (high grade dyskaryosis)
Or you may have been told you have
CIN 1 up to one third of the thickness of the lining covering the cervix has abnormal
cells
CIN 2 two thirds of the thickness of the lining covering the cervix has abnormal
cells
CIN 3 the full thickness of the lining covering the cervix has abnormal cells
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What happens after the screening test result
If you have moderate or severe cell changes on your cervix, your doctor will refer you for a
colposcopy. Most colposcopy clinics are held in hospital outpatient departments. But they are
sometimes held at community hospitals or health centres.
A colposcopy is a close examination of your cervix. A colposcope is basically a magnifying
glass. It doesn't go inside your vagina. The doctor or specialist nurse uses it to look more
closely at the abnormal areas on your cervix and may take samples of them (biopsies) to send
to the lab. You may have treatment at the same time as your colposcopy. Or you may go back
to the colposcopy clinic for treatment once they have the results of your biopsy. There is
more about colposcopy in this section.
If your screening test showed you have mild cell changes, your doctor may send you for a
colposcopy straight away. Or your doctor may ask you to go for another cervical screening
test in 6 months. This is slightly different for women having screening in England and
Northern Ireland. The NHS cervical screening programme in these countries now test the
samples of borderline or mild cell changes for the human papilloma virus (HPV). Women
who test positive for high risk types of HPV are referred for a colposcopy straight away. If
you do not have HPV, the cell changes are likely to go back to normal on their own. So you
will continue to have routine screening tests every 3 to 5 years.
If you smoke and have had a mildly abnormal screening test result, it is a good idea to try and
give up smoking if you can. You will increase the chance of your cervical cells recovering.
And your lungs will feel healthier too.
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What the treatment does
Basically all the treatments aim to do the same thing - remove or destroy the abnormal cells.
Laser ablation, cold coagulation, and cryotherapy treat just the part of the cervix that contains
abnormal cells. This allows normal cells to grow back in their place.
LLETZ, cone biopsy and hysterectomy remove the whole area of the transformation zone.
This is the area containing all the cells that could become abnormal or develop into cervical
cancer.
It is a little confusing that the terms LLETZ, NETZ, LEEP and diathermy all mean basically
the same thing - using a small tool and electric current to remove the area containing
abnormal cells from the cervix. In theory, diathermy can be used to remove just a small area
of abnormality. In practice it is the same as LLETZ as the whole transformation zone is
usually removed.
Needle excision of the transformation zone (NETZ) is similar to LLETZ. But the thin wire
used to cut away the area is straight rather than a loop.
These treatments can cause period type pains for a short time. Your usual over the counter
painkiller, such as paracetamol or ibuprofen will help.
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Laser therapy
Laser therapy is sometimes called laser ablation. This just means the laser burns away the
abnormal cells. You have this treatment as an outpatient. First, you lie on a couch, with your
legs in stirrups. Your doctor will put a speculum into your vagina to hold it open and then
puts local anaesthetic onto your cervix to numb it. Then they point the laser beam at the
abnormal areas. A laser beam is a very strong, hot beam of light. It burns away the abnormal
area. So you may notice a slight burning smell during the treatment. This is nothing to worry
about. It is just the laser working. You can go home as soon as this treatment is over.
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Cold coagulation
This is not treatment with cold as the name suggests. In fact the specialist will use a hot probe
to burn away the abnormal cells. You lie on a couch, with your legs in stirrups. The doctor
puts a speculum into your vagina to hold it open. Then the doctor uses a hot probe to destroy
the abnormal cells. You shouldn't be able to feel the probe on the cervix, but you might get a
period type pain while you are being treated and for a short while afterwards.
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Cryotherapy
The specialist uses a cold probe to freeze away the abnormal cells. You lie on a couch, with
your legs in stirrups. The doctor will put a speculum into your vagina to hold it open. Then
the doctor uses the probe to destroy the abnormal cells. You shouldn't be able to feel the
probe on the cervix, but you might get a period type pain while you are being treated and for
a short while afterwards.
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Diathermy
You have diathermy under local anaesthetic. The treatment uses an electric current to cut
away the tissue containing the abnormal cells. It is quite quick and you will be able to go
home afterwards. Bring a sanitary towel with you. You will have some bleeding or discharge
for about 4 weeks after the treatment. You shouldn't wear tampons or have sex for 4 weeks
because this will increase your risk of infection.
The advantage of diathermy, LLETZ and LEEP over laser treatment is that the piece of
cervical tissue that the doctor removes can be sent for examination under a microscope. With
laser ablation, the cells are destroyed, so the pathologist can't examine them after the
treatment.
In the laboratory, the pathologist will re check the level of cell changes in the piece of tissue
to make sure your screening result was accurate. They will also closely examine the whole
piece of tissue to make sure that the area containing the abnormal cells has been completely
removed.
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LLETZ
LLETZ stands for large loop excision of the transformation zone. In the USA, this procedure
is called LEEP loop electrosurgical excision. It is basically the same as diathermy. The area
of abnormal cells is removed completely.

It is an outpatient treatment and you usually have a local anaesthetic. If you need to have a
large area of tissue removed, or if you are very anxious about the treatment, you may have a
general anaesthetic.
You may have this treatment at the same time as your colposcopy. The transformation zone is
an area that is usually inside the endocervical canal. Its exact position varies, depending on
your age and whether you've had children. So it cannot always be seen clearly when a
screening test is taken. But it can be seen during colposcopy. It is quite common to have
abnormal cells in this area. Some doctors like to treat straight away when they find the
abnormal cells, rather than asking you to come back another time.
The transformation zone is cut away using a loop of wire and an electric current. You should
bring a sanitary towel with you to the hospital. You will need one after the treatment as there
will be some bleeding. You will have some bleeding for about 4 weeks after LLETZ. You
shouldn't wear tampons or have sex for 4 weeks because this will increase your risk of
infection.
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Cone biopsy
Your doctor may suggest this minor operation to diagnose cervical cancer or to treat
abnormal cells. As with LLETZ, the doctor removes the entire area where cells can become
abnormal (the transformation zone). It is called a cone biopsy because the surgeon removes a
cone shaped wedge of tissue from the cervix.
You may have a cone biopsy under general or local anaesthetic. There is more information
about cone biopsy in the section on diagnosing cervical cancer.
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Hysterectomy
If you are past your menopause or have had all the children you want to have, your doctor
may suggest removing the whole of your womb. This is more likely if you have had
abnormal cells found on your cervix more than once. Or if the abnormality found was severe.
In other words, you have not got cervical cancer, but the abnormal cells on your cervix are
closer to becoming cancerous cells. There is more information on hysterectomy in the section
on treating cervical cancer.
Immunotherapy/Biological Therapy
What is biological therapy?
Biological therapy (also called immunotherapy, biological response modifier therapy, or
biotherapy) uses the body's immune system to fight cancer. The cells, antibodies, and organs
of the immune system work to protect and defend the body against foreign invaders, such as
bacteria or viruses. Doctors and researchers have found that the immune system might also be
able to both determine the difference between healthy cells and cancer cells in the body, and
to eliminate the cancer cells. (By itself, the immune system is not always good at destroying
cancer cells; if it were, people would not get cancer.)
Biological therapies are designed to boost the immune system, either directly or indirectly, by
assisting in the following:
Stop, control, or suppress the processes that allow cancers to grow
Making cancer cells more recognizable by the immune system, and therefore more
susceptible to destruction by the immune system
Boosting the killing power of immune system cells
Changing the way cancer cells grow, so that they act more like healthy cells
Stopping the process that changes a normal cell into a cancerous cell
Enhancing the body's ability to repair or replace normal cells damaged or destroyed
by other forms of cancer treatment, such as chemotherapy or radiation
Preventing cancer cells from spreading to other parts of the body
Biological therapies can be used alone to treat cancer or can be combined with other
treatments such as chemotherapy and radiation therapy.
How can the immune system fight cancer?
The immune system includes different types of white blood cells, each with a different way to
fight against foreign or diseased cells, including cancer:
Lymphocytes. These are white blood cells, including B cells, T cells, and NK cells.
o B cells. Cells that produce antibodies that attack other cells.
o T cells. Cells that directly attack cancer cells themselves and signal other
immune system cells to defend the body.
o Natural killer cells (NK cells). Cells that produce chemicals that bind to and
kill foreign invaders in the body.
Monocytes. These are white blood cells that swallow and digest foreign particles.
Dendritic cells. Cells that present the foreign cells to the immune system.
These types of white blood cells--B cells, T cells, natural killer cells, and monocytes--are in
the blood and circulate to every part of the body, providing protection from cancer and other
diseases. White blood cells secrete two types of substances: antibodies and cytokines.
Antibodies respond to harmful substances that they recognize, called antigens. Specific
(helpful) antibodies match specific (foreign) antigens by locking together. Cytokines are
proteins produced by some immune system cells that attract other immune system cells or
that may directly attack cancer cells. Cytokines are messengers that communicate with other
cells.
What are the different types of biological therapies?
There are many different types of biological therapies used in cancer treatment.
Biological response modifiers (BRMs) change the way the body's defenses interact with
cancer cells. BRMs are produced naturally in the body and in a laboratory and given to
patients to:
Boost the body's ability to fight the disease.
Direct the immune system's disease fighting powers to disease cells.
Strengthen a weakened immune system.
BRMs include substances like nonspecific immunomodulating agents, interferons,
interleukins, colony-stimulating factors, monoclonal antibodies, and vaccines:
Nonspecific immunomodulating agents. Nonspecific immunomodulating agents are
biological therapy drugs that stimulate the immune system in a general way, causing it
to produce more cytokines and antibodies to help fight cancer and infections in the
body. Fighting infection is important for a person with cancer.
Interferons (IFN). Interferons are a type of biological response modifier that naturally
occurs in the body. They are also produced in the laboratory and given to cancer
patients in biological therapy. They have been shown to improve the way a cancer
patient's immune system acts against certain kinds of cancer cells. Interferons may
work directly on cancer cells to slow their growth, or they may cause cancer cells to
change into cells with more normal behavior. Some interferons may also stimulate
natural killer cells (NK) cells, T cells, and monocytes--types of white blood cells in
the bloodstream that help to fight cancer cells.
Interleukins (IL). Interleukins stimulate the growth and activity of many immune
cells. They are proteins (cytokines) that occur naturally in the body, but can also be
made in the laboratory. Some interleukins stimulate the growth and activity of
immune cells, such as lymphocytes, which work to destroy cancer cells.
Colony-stimulating factors (CSFs). Colony-stimulating factors are proteins given to
patients to encourage stem cells within the bone marrow to produce more blood cells.
The body constantly needs new white blood cells, red blood cells, and platelets,
especially when cancer is present. CSFs are sometimes given, along with
chemotherapy, to help boost the immune system. When cancer patients receive
chemotherapy, the bone marrow's ability to produce new white blood cells is
suppressed, making patients more prone to developing infections. Colony-stimulating
factors encourage the bone marrow stem cells to produce white blood cells. With
proper cell production, other cancer treatments can continue enabling patients to
safely receive higher doses of chemotherapy.
Monoclonal antibodies. Monoclonal antibodies are agents, produced in the laboratory,
that bind to specific parts of cancer cells. Some monoclonal antibodies work by
tagging cancer cells for destruction by parts of the immune system, while others work
by shutting down some function that cancer cells need to survive. Some are linked to
anticancer drugs, radioactive substances, or other biological response modifiers.
When the antibodies attach to cancer cells, they deliver these poisons directly to the
tumor, helping to destroy it. Monoclonal antibody agents generally do not affect
healthy cells.
Vaccine therapy. Vaccine therapy is a growing area of cancer research. The idea of
vaccine therapy is to get the body's immune system to start attacking the cancer cells
in the body. With infectious diseases, vaccines are given before the disease develops.
Cancer vaccines, however, are usually given after the disease develops, when the
tumor is small. They may also be given to a healthy person before cancer develops,
with the hopes of stimulating the immune system to attack viruses that cause cancer.
Scientists are testing the value of vaccines in treating many types of cancer.
Sometimes, vaccines are combined with other biological therapies.
types of biological therapies?
There are many different types of biological therapies used in cancer treatment.
Biological response modifiers (BRMs) change the way the body's defenses interact with
cancer cells. BRMs are produced naturally in the body and in a laboratory and given to
patients to:
Boost the body's ability to fight the disease.
Direct the immune system's disease fighting powers to disease cells.
Strengthen a weakened immune system.
BRMs include substances like nonspecific immunomodulating agents, interferons,
interleukins, colony-stimulating factors, monoclonal antibodies, and vaccines:
Nonspecific immunomodulating agents. Nonspecific immunomodulating agents are
biological therapy drugs that stimulate the immune system in a general way, causing it
to produce more cytokines and antibodies to help fight cancer and infections in the
body. Fighting infection is important for a person with cancer.
Interferons (IFN). Interferons are a type of biological response modifier that naturally
occurs in the body. They are also produced in the laboratory and given to cancer
patients in biological therapy. They have been shown to improve the way a cancer
patient's immune system acts against certain kinds of cancer cells. Interferons may
work directly on cancer cells to slow their growth, or they may cause cancer cells to
change into cells with more normal behavior. Some interferons may also stimulate
natural killer cells (NK) cells, T cells, and monocytes--types of white blood cells in
the bloodstream that help to fight cancer cells.
Interleukins (IL). Interleukins stimulate the growth and activity of many immune
cells. They are proteins (cytokines) that occur naturally in the body, but can also be
made in the laboratory. Some interleukins stimulate the growth and activity of
immune cells, such as lymphocytes, which work to destroy cancer cells.
Colony-stimulating factors (CSFs). Colony-stimulating factors are proteins given to
patients to encourage stem cells within the bone marrow to produce more blood cells.
The body constantly needs new white blood cells, red blood cells, and platelets,
especially when cancer is present. CSFs are sometimes given, along with
chemotherapy, to help boost the immune system. When cancer patients receive
chemotherapy, the bone marrow's ability to produce new white blood cells is
suppressed, making patients more prone to developing infections. Colony-stimulating
factors encourage the bone marrow stem cells to produce white blood cells. With
proper cell production, other cancer treatments can continue enabling patients to
safely receive higher doses of chemotherapy.
Monoclonal antibodies. Monoclonal antibodies are agents, produced in the laboratory,
that bind to specific parts of cancer cells. Some monoclonal antibodies work by
tagging cancer cells for destruction by parts of the immune system, while others work
by shutting down some function that cancer cells need to survive. Some are linked to
anticancer drugs, radioactive substances, or other biological response modifiers.
When the antibodies attach to cancer cells, they deliver these poisons directly to the
tumor, helping to destroy it. Monoclonal antibody agents generally do not affect
healthy cells.
Vaccine therapy. Vaccine therapy is a growing area of cancer research. The idea of
vaccine therapy is to get the body's immune system to start attacking the cancer cells
in the body. With infectious diseases, vaccines are given before the disease develops.
Cancer vaccines, however, are usually given after the disease develops, when the
tumor is small. They may also be given to a healthy person before cancer develops,
with the hopes of stimulating the immune system to attack viruses that cause cancer.
Scientists are testing the value of vaccines in treating many types of cancer.
Sometimes, vaccines are combined with other biological therapies.
Are there side effects of biological therapies?
As each person's medical profile and diagnosis is different, so is his or her reaction to
treatment. Side effects may be severe, mild, or absent. Be sure to discuss with your cancer
care team any or all possible side effects of treatment before the treatment begins.
Side effects of biological therapy vary according to the type of therapy given and may
include the following:
Fever
Chills
Nausea
Vomiting
Loss of appetite
Fatigue
Specifically, interleukins and interferons often cause flulike symptoms, such as fever, chills,
aches, and fatigue. Other side effects may include a rash or swelling at the injection site.
Interleukins can be associated with low blood pressure and generally require close monitoring
in the hospital during infusion. Monoclonal antibodies sometimes cause allergic reactions.
Some treatment can cause fatigue and bone pain and may affect blood pressure and the heart.
Cancers Treated with Proton Therapy

Proton therapy is a noninvasive and extremely precise treatment option, and alone, or in
combination with other treatments, can be extremely effective treatment for many specific
types of cancers.
Cancer Types
Proton therapy is used for a variety of cancer types, and at Penn Medicine we are constantly
working to expand the list of conditions treated with proton therapy.
Below are some of the cancers treated with proton therapy:
Brain cancer and spinal tumors
Breast cancer
Gastrointestinal (GI) cancer (colon, esophageal, kidney, pancreatic)
Gynecologic (cervical cancer)
Head and neck cancer
Lung cancer
Lymphoma
Mesothelioma
Pediatric cancer, in conjunction with the Children's Hospital of Philadelphia
Prostate cancer
Sarcomas
Proton therapy is also a potential treatment option for cancer that cannot be completely
removed by surgery, as well as recurrent cancer.
Is Proton Therapy Right for Me?
Proton therapy may not always be the best option for your type of cancer.
Chemotherapy, surgery, or conventional radiation therapy may be the best treatment for some
cancers. In addition, proton therapy may be used in conjunction with one or more of these
therapies.
Before starting treatment for cancer, you will meet with your team of experts who are
national leaders in your cancer type. Together, they will work with you to determine your
best treatment options.
Because every type of cancer treatment, as well as comprehensive medical care and support
services, is available right here at Penn's worldrenowned Abramson Cancer Center, you'll be
able to see all your doctors and learn about all your options in one location.
What is Proton Therapy?

"Proton therapy potentially represents the best of both worlds delivering a high dose of
radiation to tumors, while at the same time limiting side effects to patients."
Stephen Hahn, MD, Chairman of the Department of Radiation Oncology at Penn Medicine
Proton therapy is a noninvasive, incredibly precise cancer treatment that uses a beam of
protons moving at very high speeds to destroy the DNA of cancer cells, killing them and
preventing them from multiplying.
The Benefits of Proton Therapy at Roberts Proton
Therapy Center
Unlike conventional radiation that can affect surrounding healthy tissue as it enters the body
and targets the tumor, proton therapy's precise, high dose of radiation is extremely targeted.
This targeted precision causes less damage to healthy, surrounding tissue.
When aimed at cancer tumors, protons pack impressive power. Protons release their energy
completely once they enter a tumor, limiting the radiation dose beyond the tumor, causing
less damage to the healthy surrounding tissues and resulting in fewer side effects.
Even if you've already had a course of conventional radiation and are unable to receive more,
you may still be able to receive proton therapy.
More facts about proton therapy:
Proton therapy offers fewer reported side effects and complications
Normal, healthy, surrounding tissues receive 50% to 70% less radiation
Proton therapy offers an increased safe dose delivered to tumors
Cure rates may be increased with proton therapy
Proton therapy can retreat tumors after recurrences
Increased Precision Close to Critical Organs
Thanks to its marvelous precision, proton therapy is perhaps the most advanced treatment for
cancer tumors located close to critical organs and highly sensitive areas, such as the spinal
cord, heart and brain.
Proton therapy, alone or in combination with other treatments, is a great choice for many
specific types of cancers and benign conditions.
Proton therapy is also an important treatment option for cancers that cannot be completely
removed by surgery.
How Proton Therapy Works
At the center of the cyclotron, protons from hydrogen gas are guided in a circular path by a
powerful magnet and are accelerated to higher and higher energies. As the protons gain
energy, they spiral outward to the edge of the cyclotron magnet where, traveling at close to
twothirds of the speed of light, a high voltage deflects them out of the cyclotron into a
beamline. The beamline is an airless tube that runs for about the length of a football field in
which the proton beam is guided by other magnets into the treatment rooms.
Inside the treatment room, the proton beam exits the beamline through the "nozzle" where the
beam energy is adjusted and a multileaf collimator precisely shapes it to match the unique
3D profile of the patient's tumor delivering the most effective dose exactly where it's
needed.
MultiLeaf Collimator (MLC)
Penn is one of the few centers in the world, and the only facility in the United States, to offer
the additional precision of a multileaf collimator (MLC).
This tool enables us to deliver protons in the exact shape needed for your tumor, delivering
optimum results, each and every time.
Pencil Beam Proton Therapy
The Roberts Proton Therapy Center is one of the few centers in the world that offers pencil
beam scanning (PBS). Proton therapy delivered with PBS allows doctors to "paint" the tumor
with a proton beam tuned to a precise range, as well as adjust the intensity of the beam to
achieve the desired dose distribution.
Pencil beam scanning is ideal for complex cancers, in which the tumor is located near critical
structures.
You'll find the world's largest, most advanced proton therapy capabilities in Philadelphia at
the Roberts Proton Therapy Center at Penn Medicine.
Hormone Therapy
What is hormone therapy?
Hormones are chemicals produced by glands, such as the ovaries and testicles. Hormones
help some types of cancer cells to grow, such as breast cancer and prostate cancer. In other
cases, hormones can kill cancer cells, make cancer cells grow more slowly, or stop them from
growing. Hormone therapy as a cancer treatment may involve taking medications that
interfere with the activity of the hormone or stop the production of the hormones. Hormone
therapy may involve surgically removing a gland that is producing the hormones.
How does hormone therapy work?
Your physician may recommend a hormone receptor test to help determine treatment options
and to help learn more about the tumor. This test can help to predict whether the cancer cells
are sensitive to hormones.
The hormone receptor test measures the amount of certain proteins (called hormone
receptors) in cancer tissue. Hormones (such as estrogen and progesterone that naturally occur
in the body) can attach to these proteins. If the test is positive, it is indicating that the
hormone is probably helping the cancer cells to grow. In this case, hormone therapy may be
given to block the way the hormone works and help keep the hormone away from the cancer
cells (hormone receptors). If the test is negative, the hormone does not affect the growth of
the cancer cells, and other effective cancer treatments may be given. Always discuss the
results of the hormone receptor test with your physician.
If the test indicates that the hormones are affecting your cancer, the cancer may be treated in
one of following ways:
Treating cancer cells to keep them from receiving the hormones they need to grow
Treating the glands that produce hormones to keep them from making hormones
Surgery to remove glands that produce the hormones, such as the ovaries that produce
estrogen, or the testicles that produce testosterone
The type of hormone therapy a person receives depends upon many factors, such as the type
and size of the tumor, the age of the person, the presence of hormone receptors on the tumor,
and other factors.
When is hormone therapy given?
Your physician may prescribe hormone therapies before some cancer treatments or after other
cancer treatments. If hormone therapy is given before the primary treatment, it is called
neoadjuvant treatment. Neoadjuvant treatments help to kill cancer cells and contribute to the
effectiveness of the primary therapy. If hormone therapy is given after the primary cancer
treatment, it is called adjuvant treatment. Adjuvant therapy is given to improve the chance of
a cure.
With some cancers, patients may be given hormone therapy as soon as cancer is diagnosed,
and before any other treatment. It may shrink a tumor or it may halt the advance of the
disease. And in some cancer, such as prostate cancer, it is helpful in alleviating the painful
and distressing symptoms of advanced disease. The National Cancer Institute (NCI) states
that although hormone therapy cannot cure prostate cancer, it will usually shrink or halt the
advance of disease, often for years.
The Gerson Therapy
he Gerson Therapy is a natural treatment that activates the bodys extraordinary ability to
heal itself through an organic, plant-based diet, raw juices, coffee enemas and natural
supplements.
With its whole-body approach to healing, the Gerson Therapy naturally reactivates your
bodys magnificent ability to heal itself with no damaging side effects. This a powerful,
natural treatment boosts the bodys own immune system to heal cancer, arthritis, heart
disease, allergies, and many other degenerative diseases. Dr. Max Gerson developed the
Gerson Therapy in the 1930s, initially as a treatment for his own debilitating migraines, and
eventually as a treatment for degenerative diseases such as skin tuberculosis, diabetes and,
most famously, cancer.

Learn more about Dr. Max Gerson

The Gerson Therapys all-encompassing nature sets it apart from most other treatment
methods. The Gerson Therapy effectively treats a wide range of different ailments because it
restores the bodys incredible ability to heal itself. Rather than treating only the symptoms of
a particular disease, the Gerson Therapy treats the causes of most degenerative diseases:
toxicity and nutritional deficiency.
An abundance of nutrients from copious amounts of fresh, organic juices are consumed every
day, providing your body with a super-dose of enzymes, minerals and nutrients. These
substances then break down diseased tissue in the body, while coffee enemas aid in
eliminating toxins from the liver.
Throughout our lives our bodies are being filled with a variety of carcinogens and toxic
pollutants. These toxins reach us through the air we breathe, the food we eat, the medicines
we take and the water we drink. The Gerson Therapys intensive detoxification regimen
eliminates these toxins from the body, so that true healing can begin.
the Gerson Therapy Works
The Gerson Therapy regenerates the body to health, supporting each important metabolic
requirement by flooding the body with nutrients from about 15- 20 pounds of organically
grown fruits and vegetables daily. Most is used to make fresh raw juice, up to one glass
every hour, up to 13 times per day. Raw and cooked solid foods are generously consumed.
Oxygenation is usually more than doubled, as oxygen deficiency in the blood contributes to
many degenerative diseases. The metabolism is also stimulated through the addition of
thyroid, potassium and other supplements, and by avoiding heavy animal fats, excess protein,
sodium and other toxins.
Degenerative diseases render the body increasingly unable to excrete waste materials
adequately, commonly resulting in liver and kidney failure. The Gerson Therapy uses
intensive detoxification to eliminate wastes, regenerate the liver, reactivate the immune
system and restore the bodys essential defenses enzyme, mineral and hormone systems.
With generous, high-quality nutrition, increased oxygen availability, detoxification, and
improved metabolism, the cells and the body can regenerate, become healthy and prevent
future illness.
Juicing

Fresh pressed juice from raw foods provides the easiest and most effective way of providing
high quality nutrition. By juicing, patients can take in the nutrients and enzymes from nearly
15 pounds of produce every day, in a manner that is easy to digest and absorb.
Every day, a typical patient on the Gerson Therapy for cancer consumes up to thirteen glasses
of fresh, raw carrot/apple and green-leaf juices. These juices are prepared hourly from fresh,
raw, organic fruits and vegetables, using a two-step juicer or a masticating juicer used with a
separate hydraulic press.
The Gerson Guide to Juicers
FAQs: Juicing & Juicers
The Gerson Diet
The Gerson diet is plant-based and entirely organic. The diet is naturally high in vitamins,
minerals, enzymes, micro-nutrients, and extremely low in sodium, fats, and proteins. The
following is a typical daily diet for a Gerson patient on the full therapy regimen:
Thirteen glasses of fresh, raw carrot/apple and green-leaf juices prepared hourly
from fresh, organic fruits and vegetables.
Three full plant-based meals, freshly prepared from organically grown fruits,
vegetables and whole grains. A typical meal will include salad, cooked vegetables,
baked potatoes, Hippocrates soup and juice.
Fresh fruit and fresh fruit available at all hours for snacking, in addition to the regular
diet.
To learn more about the Gerson diet, follow the link below to read about which foods are
permitted and prohibited on the Gerson Therapy:
Supplements
All medications used in connection with the Gerson Therapy are classed as biologicals,
materials of organic origin that are supplied in therapeutic amounts.
Potassium compound
Lugols solution
Vitamin B-12
Thyroid hormone
Pancreatic Enzymes
Detoxification
Coffee enemas are the primary method of detoxification of the tissues and blood on the
Gerson Therapy. Cancer patients on the Gerson Therapy may take up to 5 coffee enemas per
day. Charlotte Gerson explains the necessity of coffee enemas in Healing the Gerson Way:
The moment a patient is put on the full therapy, the combined effect of the food, the juices
and the medication causes the immune system to attack and kill tumor tissue, besides
working to flush out accumulated toxins from the body tissues. This great clearing-out
procedure carries the risk of overburdening and poisoning the liverthe all-important organ
of detoxification, which, in a cancer patient, is bound to be already damaged and debilitated.
Coffee enemas accomplish this essential task, assisting the liver in eliminating toxic residues
from the body for good. The Gerson Therapy also utilizes castor oil to stimulate bile flow and
enhance the livers ability to filter blood.
s the Gerson Therapy Right For You?
No treatment works for everyone, every time. Anyone who tells you otherwise is not giving
you the facts. We know that when you have been diagnosed with a life-threatening ailment,
choosing the best strategy for fighting your illness can be a bewildering task. Everyone
claims to have either the best treatment, the fastest cure, or the only therapy that works.
In most cases your trusted family physician only has knowledge of conventional treatments,
and is either unaware of, or even hostile toward alternative options.
No matter how many opinions you receive on how to treat your disease, you are going to
make the final decision on what to do, and you must be comfortable with your decision.
Choose a treatment that makes the most sense to you.
Most therapiesconventional or alternativetreat only the individual symptoms while
ignoring what is ultimately causing the disease. The reason the Gerson Therapy is effective
with so many different ailments is because it restores the bodys incredible ability to heal
itself. Rather than treating only the symptoms of a particular disease, the Gerson Therapy
treats the cause of the disease itself. Although we feel the Gerson Therapy is the most
comprehensive treatment for disease, we dont claim it will cure everything or everyone.
Caution: Do not start the Gerson Therapy if any of the following conditions apply
without referring to Charlotte Gersons book, Healing the Gerson Way, or without the
supervision of a Gerson doctor:
Chemotherapy
Diabetes
Brain metastases
Severe kidney damage and/or if the patient has ever been on dialysis
Foreign bodies such as pacemakers, breast implants, steel plates or screws.
Patients must be able to eat, drink and eliminate normally. The Gerson Therapy cannot be
administered to organ transplant recipients. See our FAQs to learn more about which
conditions are contraindicated for the Gerson Therapy, and which conditions respond well to
the Therapy.
FAQs General Information

Are you thinking of following the Gerson Therapy?
Read our Get Started page to see our recommendations for beginning the Gerson Therapy.
Based on our experience and the experiences of countless other patients, weve assembled
this guide that takes you from the moment you first hear of the Gerson Therapy to your first
day on the full protocol!